|Year : 2016 | Volume
| Issue : 2 | Page : 144-146
Tuberculous appendicitis: A rare case report
Subrata Pal1, Kingshuk Bose2, Monoj Chowdhury3, Mrinal Sikder4
1 Department of Pathology, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal, India
2 Department of Pathology, Bankura Sammilani Medical College, Bankura, West Bengal, India
3 Department of Pathology, IPGMER, Kolkata, West Bengal, India
4 Department of Pathology, Calcutta National Medical College, Kolkata, West Bengal, India
|Date of Web Publication||29-Feb-2016|
Sodepur, Panihati, North 24 Parganas, West Bengal
Source of Support: None, Conflict of Interest: None
Tuberculosis (TB) in appendix is a very rare occurrence. Clinical diagnosis is often not possible. Histopathological examination confirms the diagnosis of tuberculous appendicitis. Postoperative antitubercular drug treatment is compulsory for management. We are presenting a case of TB of appendix, which was presented with acute abdomen and diagnosed in histopathological examination.
Keywords: Appendicitis, histopathology, tuberculosis
|How to cite this article:|
Pal S, Bose K, Chowdhury M, Sikder M. Tuberculous appendicitis: A rare case report. CHRISMED J Health Res 2016;3:144-6
| Introduction|| |
Tuberculosis (TB) of appendix is very rare even in countries where TB is endemic. Prevalence of primary tubercular appendicitis varies from 0.1% to 3.0% of all appendectomy specimens and secondary tubercular involvement in the case of diagnosed TB is 1.5–30% in previous literatures. Preoperative etiological diagnosis is often not possible, especially when it presents with features of acute appendicitis. In most of the cases, tubercular appendicitis is a histopathological diagnosis. Here, we are presenting a case of primary tubercular appendicitis diagnosed by histopathological examination of an appendectomy specimen.
| Case Report|| |
A 17-year-old male patient was admitted in the emergency surgical ward of our hospital with complaints of acute severe abdominal pain at right iliac fossa, vomiting, and fever for 2 days. On general examination, he was of average built and well nourished. Abdominal examination revealed tenderness and guarding at McBurney's point. No palpable lump was found. Examination findings of other systems were within normal limit. In routine hematological examination, the patient had neutrophilic leukocytosis (total leukocyte count - 11,800/cmm). Chest X-ray did not show any abnormality and on abdominal ultrasound, appendix was not visualized. Depending on the clinical diagnosis, appendectomy was done. On exploration, appendix was thick, inflamed with few adhesion at periappendicular tissue. Surgery was uncomplicated, and the specimen was sent for histopathological examination.
On gross examination, appendix and periappendicular fatty tissue were measuring 7 cm in length and gray. On cut section, wall was thickened. On microscopical examination, multiple well-defined epithelioid granulomas, caseation necrosis, and Langhan's type giant cells surrounded by chronic inflammatory cells infiltration were found in submucosal and muscular layer of appendix [Figure 1],[Figure 2],[Figure 3]. Final histopathological diagnosis of tubercular appendicitis was made.
|Figure 1: The sections show many epithelioid granulomas and Langhans giant cells with central caseation necrosis in submucosal and muscular layer (H and E stain, scanner view)|
Click here to view
|Figure 2: Photomicrograph reveals central caseous necrosis, epithelioid granulomas, and Langhans giant cells in muscular layer with chronic inflammatory cell infiltration (H and E stain, low power view)|
Click here to view
|Figure 3: Photomicrograph shows central caseous necrosis, epithelioid granulomas, and Langhans giant cells (high power view, H and E stain)|
Click here to view
Subsequently, he was treated by CAT-I antitubercular drugs (ATDs) according to national program on outpatient department basis. Other necessary investigations (sputum for acid fast Bacilli, chest X-ray) were carried out before starting ATD, but did not reveal any pulmonary lesion. Routine clinical and laboratory findings failed to show any other extrapulmonary site involvement. The patient was responded well in ATD and 2-year follow-up was satisfactory.
| Discussion|| |
Incidence of primary TB of appendix is very rare, ranging from 0.1% to 3% of all appendectomies., Secondary tubercular appendicitis is reported in 1.5–3% of cases. Most of the secondary cases were before the advent of novel chemotherapeutic ATDs. TB of gastrointestinal (GI) tract most commonly involves ileocecal region. Rarity of appendicular involvement is due to minimal contact of appendicular mucosa with the intestinal contents. Pathology of tubercular appendicitis has been explained by hematogenous spread, spread by infected intestinal contents, extension from adjacent ileocecal TB, lymphatic spread from distant GI lesions, peritoneal spread, and multi-organ involvement in different literatures.,, Diagnosis of primary tubercular appendicitis ideally needs exclusion of involvement of other organs by autopsy. However, for the practical purpose, we searched extensively by clinical, radiological, and other relevant investigations for exclusion of secondary involvement.
According to clinical presentations, three types of tubercular appendicitis had been described by Singh et al. Most common is chronic form presents with vague mild-to-moderate abdominal pain at right iliac fossa, associated with anorexia, nausea, and vomiting. The second type presents with signs and symptoms of acute appendicitis as in our case. The third presentation is an incidental histopathological finding of tubercular appendicitis.,, Acute presentation, in this case, can be explained by pyogenic superinfection on tubercular etiology. Clinical diagnosis of tubercular appendicitis is difficult as no clinical feature is pathognomonic for tubercular appendicitis. However, poor nutritional status and vague recurrent pain with weight loss in young age may be indications of tubercular etiology, particularly in countries where TB is endemic.
Initial management of acute appendicitis even of tubercular etiology is an appendectomy. ATD should be started early after histopathological diagnosis.
| Conclusion|| |
Although TB of appendix is a rare disease even in the endemic area, surgeons must be aware of the possibility. As treatment of tubercular appendicitis is beyond the surgical intervention, every resected appendix should be sent for histopathological examination.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Chong VH, Telisinghe PU, Yapp SK, Chong CF. Tuberculous appendix: A review of clinical presentations and outcomes. Singapore Med J 2011;52:90-3.
Nuwal PI, Dixit R, Jain S, Porwal V. Isolated appendicular tuberculosis – A case report. Indian J Tuberc 2000;47:241-2.
Gupta S, Kaushik R, Kaur A, Attri AK. Tubercular appendicitis – A case report. World J Emerg Surg 2006;1:22.
Ammanagi A, Dhobale V, Patil B, Miskin A. Isolated appendicular tuberculosis. J Glob Infect Dis 2011;3:102-3.
Singh MK, Arunabh, Kapoor VK. Tuberculosis of the appendix – A report of 17 cases and a suggested aetiopathological classification. Postgrad Med J 1987;63:855-7.
[Figure 1], [Figure 2], [Figure 3]